By Counterforce Health Team in Tysabri (natalizumab) —

How to Get Tysabri (Natalizumab) Covered by Blue Cross Blue Shield of North Carolina: Complete Prior Authorization Guide

Answer Box: Getting Tysabri Covered by BCBS North Carolina

Eligibility: Tysabri (natalizumab) requires prior authorization from Blue Cross Blue Shield of North Carolina for both commercial and Medicare members. Coverage is typically approved for relapsing multiple sclerosis when step therapy requirements are met and proper clinical documentation is provided.

Fastest Path: 1) Verify your plan's formulary status using your member portal, 2) Have your neurologist submit prior authorization via Availity Essentials with MRI results and JCV antibody status, 3) If denied, file internal appeal within plan deadlines, then external review through Smart NC if needed.

Start Today: Call BCBS NC member services (number on your ID card) to confirm Tysabri's tier placement and PA requirements for your specific plan.

Table of Contents

Plan Types & Coverage Implications

Blue Cross Blue Shield of North Carolina offers several plan types that affect how Tysabri coverage works:

Commercial Plans (employer-sponsored and individual market) typically require prior authorization for Tysabri, with coverage varying by formulary tier. Most commercial plans place Tysabri on Tier 4 (specialty) or Tier 5 (highest cost-sharing) depending on whether you have a 4-tier or 5-tier formulary structure.

Medicare Advantage Plans follow Medicare Part B guidelines for provider-administered medications like Tysabri. These plans often have stricter step therapy requirements and may require you to try oral DMTs first.

State Employee Health Plan members have access to the same external review rights through Smart NC as other state-regulated plans, which can be crucial for expensive specialty medications.

Note: Self-funded employer plans (ERISA) don't fall under North Carolina's external review system, though some employers voluntarily participate.

Formulary Status & Tier Placement

Tysabri's formulary status varies by your specific BCBS NC plan. To check your coverage:

  1. Log into your member portal
  2. Enter your plan's Rx letter code (found on your member ID card)
  3. Search for "natalizumab" or "Tysabri"

Typical Tier Placement:

  • 4-Tier Plans: Usually Tier 4 (specialty)
  • 5-Tier Plans: Usually Tier 5 (highest cost-sharing)
  • Medicare Plans: Covered under medical benefit (Part B) when provider-administered

The formulary is reviewed quarterly and can change, so verify status before each treatment cycle.

Prior Authorization Requirements

All BCBS NC plans require prior authorization for Tysabri. Your neurologist must submit documentation through the Availity Essentials portal including:

Required Clinical Documentation:

  • Multiple sclerosis diagnosis with supporting MRI evidence
  • Recent MRI showing disease activity (new or enhancing lesions)
  • JCV (John Cunningham Virus) antibody test results
  • Documentation of previous DMT trials and outcomes
  • Clinical rationale for Tysabri necessity

TOUCH Program Enrollment: Tysabri requires enrollment in the manufacturer's TOUCH program due to PML (progressive multifocal leukoencephalopathy) risk. Missing TOUCH enrollment is a common denial reason.

Clinician Tip: Submit comprehensive documentation upfront. Incomplete submissions delay approval and may result in automatic denials.

Step Therapy & Alternative DMTs

BCBS NC typically requires you to try preferred DMTs before approving Tysabri coverage. Common step therapy requirements include:

Preferred First-Line DMTs:

  • Oral medications: dimethyl fumarate, teriflunomide, fingolimod
  • Injectable medications: glatiramer acetate, interferon beta preparations

Step Therapy Exceptions: Your doctor can request an override if:

  • You've failed or cannot tolerate preferred alternatives
  • Preferred DMTs are contraindicated
  • Clinical evidence supports Tysabri as first-line therapy

Alternative High-Efficacy DMTs: If Tysabri is denied, similar alternatives include Ocrevus (ocrelizumab), Kesimpta (ofatumumab), or Mavenclad (cladribine).

Specialty Pharmacy Network

Tysabri must be obtained through BCBS NC's specialty pharmacy network. The process works as follows:

  1. Prior authorization approval triggers prescription routing to contracted specialty pharmacy
  2. Pharmacy assignment may occur through the Advocate+ Pharmacy Match program for certain employer plans
  3. Patient onboarding includes insurance verification, clinical education, and delivery coordination
  4. Infusion coordination since Tysabri is provider-administered, not self-injected

The specialty pharmacy will contact you directly to initiate setup once your prescription is approved and assigned.

Cost-Share Basics

Your out-of-pocket costs depend on your plan design:

Commercial Plans:

  • Deductible may apply before coverage begins
  • Coinsurance typically 10-40% for specialty tiers
  • Out-of-pocket maximums provide annual cost protection

Medicare Plans:

  • Part B deductible applies ($240 in 2024)
  • 20% coinsurance after deductible
  • Supplemental coverage may reduce costs
Important: Cost-sharing information is educational only. Verify your specific benefits with BCBS NC member services.

Submission Process & Documentation

For Providers: Availity Essentials Portal

All prior authorization requests must be submitted through Availity Essentials. Key steps include:

  1. CPT/HCPCS Code: Use J2323 for natalizumab
  2. Required Fields: Complete all clinical documentation sections
  3. Supporting Documents: Attach MRI reports, JCV results, treatment history
  4. Appeals: Use same portal for internal appeals with additional documentation

Alternative Submission Methods

  • Phone: 833-540-2106 for urgent cases
  • Fax: Available through Availity portal (verify current number)

Appeals Playbook for North Carolina

If your Tysabri request is denied, North Carolina offers robust appeal rights:

Internal Appeals (BCBS NC)

Timeline: File within 60 days of denial notice Process: Submit through Availity portal or member services Documentation: Include additional clinical evidence, peer-reviewed studies, treatment guidelines

External Review (Smart NC)

Eligibility: After exhausting internal appeals Timeline: File within 120 days of final internal denial Contact: Smart NC at 855-408-1212 Process:

  • Standard review: 45 days for decision
  • Expedited review: 72 hours for urgent cases
  • Binding decision: BCBS NC must comply within 3 business days if overturned
From our advocates: We've seen Tysabri denials successfully overturned at external review when patients provided comprehensive MRI documentation showing disease progression and detailed records of failed prior therapies. The key is thorough clinical documentation that directly addresses the plan's specific denial reasons.

Common Denial Reasons & Solutions

Denial Reason Solution Strategy
Missing TOUCH enrollment Complete TOUCH program registration before resubmission
Inadequate MRI documentation Submit recent MRI with radiologist interpretation showing active disease
Step therapy not completed Document failed trials of preferred DMTs or request medical exception
JCV status unclear Provide current JCV antibody test results and PML risk assessment
Quantity/frequency limits Submit dosing rationale based on FDA labeling and clinical guidelines

When to Contact Smart NC

Contact Smart NC at 855-408-1212 if:

  • BCBS NC denies your internal appeals
  • You need help navigating the external review process
  • You want free advocacy assistance with your case
  • You're facing urgent treatment delays

Smart NC staff can help you build a stronger case with clinical evidence and ensure you meet all procedural requirements.

Patient Support Programs

Biogen Support: The manufacturer offers the TYSABRI TOUCH Prescribing Program with patient support services and potential financial assistance.

Copay Assistance: Commercial insurance patients may qualify for copay cards to reduce out-of-pocket costs (Medicare patients are not eligible).

Foundation Grants: Organizations like the National MS Society may provide financial assistance for eligible patients.

Counterforce Health helps patients and providers turn insurance denials into successful appeals by analyzing denial letters, identifying specific coverage criteria, and drafting evidence-based rebuttals that address payer requirements point-by-point. Their platform streamlines the appeals process by pulling relevant clinical citations and ensuring submissions meet procedural requirements for each payer's workflow.

Frequently Asked Questions

How long does BCBS NC prior authorization take? Standard prior authorization decisions are typically made within 14 days. Expedited reviews for urgent cases can be completed in 72 hours.

What if Tysabri isn't on my formulary? You can request a formulary exception with clinical documentation showing medical necessity. If denied, appeal through internal and external review processes.

Can I get expedited approval for urgent cases? Yes, both BCBS NC and Smart NC offer expedited review processes for urgent medical situations where delays could harm your health.

Does step therapy apply if I failed DMTs outside North Carolina? Yes, document all prior therapy trials regardless of where they occurred. Out-of-state treatment records are valid for step therapy documentation.

What's the success rate for Tysabri appeals in North Carolina? Specific success rates aren't publicly available, but Smart NC's external review process provides an independent, binding review that has overturned many specialty drug denials.

How do I find my plan's specific formulary? Use the BCBS NC drug search tool with your plan's Rx letter code from your member ID card.

Sources & Further Reading

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about your specific treatment options and insurance coverage. Coverage decisions depend on your individual plan benefits and clinical circumstances.

For personalized help with insurance appeals and prior authorization, Counterforce Health provides specialized support for patients and providers navigating complex coverage requirements for specialty medications like Tysabri.

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